Basic Information
| Provider Information | |||||||||
| NPI: | 1477696805 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MUNICIPIO DE ISABELA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CENTRO ISABELINO DE MEDICINA AVANZADA | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 737 | ||||||||
| Address2: | |||||||||
| City: | ISABELA | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7878302705 | ||||||||
| FaxNumber: | 7878300465 | ||||||||
| Practice Location | |||||||||
| Address1: | AVE. AGUSTIN R CALERO | ||||||||
| Address2: | KM 1.1 | ||||||||
| City: | ISABELA | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7878302705 | ||||||||
| FaxNumber: | 7878300465 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2007 | ||||||||
| LastUpdateDate: | 05/02/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VAN DERDYS | ||||||||
| AuthorizedOfficialFirstName: | GISSELLE | ||||||||
| AuthorizedOfficialMiddleName: | K. | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRADOR | ||||||||
| AuthorizedOfficialTelephone: | 7878302705 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MUNICIPIO DE ISABELA | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MHSA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.